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Syndrome of transtentorial herniation: is vertical displacement necessary?
1St Elizabeth's Hospital, Boston, MA 02135.
Abstract:
MRI from a comatose patient with a massive acute subdural haematoma showed most of the features of transtentorial herniation described in the classic pathology literature. In addition to encroachment on the perimesencephalic cisterns, infarction in the anterior and posterior cerebral artery territories, ischaemic change in the lower diencephalon, and ventricular enlargement were visualised. Despite the clinical syndrome and these secondary changes due to compression, there was only approximately 2 mm of downward displacement of the upper brainstem compared with 13 mm horizontal displacement. Although tissue shifts adjacent to the tentorial aperture cause brainstem and vascular compression, these changes may occur with minimal downward herniation.
Insights
Acute subdural hematoma can cause transtentorial herniation with minimal downward brainstem shift. MRI reveals secondary changes like infarction and ventricular enlargement, despite limited vertical displacement.
Area of Science:
- Neurology
- Radiology
- Pathology
Background:
- Acute subdural hematomas (ASDH) are a common cause of severe traumatic brain injury.
- Transtentorial herniation is a critical complication of intracranial mass effect.
Observation:
- MRI in a comatose patient with ASDH demonstrated features consistent with transtentorial herniation.
- Observed were perimesencephalic cistern encroachment, cerebral artery territory infarctions, and ventricular enlargement.
Findings:
- Despite significant clinical signs and secondary ischemic changes, the downward displacement of the upper brainstem was minimal (approx. 2 mm).
- Horizontal displacement of the brainstem measured 13 mm.
Implications:
- Tissue shifts at the tentorial aperture can cause brainstem and vascular compression even with minimal downward herniation.
- These findings challenge traditional assumptions about the degree of downward displacement required for herniation complications.